Basic Information
| Provider Information | |||||||||
| NPI: | 1063621670 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAIRD | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | N | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16248 VICTOR ST | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923953934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602437151 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15447 ANACAPA RD STE 104 | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923922481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602459446 | ||||||||
| FaxNumber: | 7607518986 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2007 | ||||||||
| LastUpdateDate: | 09/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | AII11511215 | CA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | RW1055 | CA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 109564 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 5089 | 01 | CA | SIMON STAFF NUMBER | OTHER |